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q SNS - IE SAN JOAQUIN COUNTY f MPv 9 ENVIRONMENTAL HEALTH DEPARTMENT LOP dOPnU) 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SITE MITIGATION r=o5 t4kp one% (209) 468-3464 Fax: (209) 468-3433 Web: www.s*ciov.orci/ehd UNIT IV WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the Standards of the San Joaquin County Environmental Health Department. Site Location 517 West Fremont St Gross Street North Lincoln City Stockton Zip 95203 APN 137 - 214 - 10 Property 517 West Fremont St Stockton 95203 209 -466-9678 owner David and Patrice Guardino Address City Zip Phone C-57 Contractor All Well Abandonment Address 9245 Beatty Drive City Sacramento Lie 848Phone 359 916 - 363 - 9355 Advanced GeoEnvironmental 837 Shaw Road Stockton 680227 209 - 467 - 1006 Consultant/Sub Cntr Address City Lic Phone Billable Party AGE Address 837 Shaw Road City Stockton Zip 95215 Phone 209 - 467 -1006 GIS Coordinates: X Y n R r l N e 1 CONSTRUCTION WORK TO BE PERFORMED: VV wow ❑x NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER) ❑ SOIL BORING IDs ❑x WELLIDs iAs- 2 . IAS- 3 . IAS -4 . IAS - S and Vw- 2 ❑ OTHER IDS TYPE 8 # OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑ MONITORING EI HOLLOW STEM DIA. OF BOREHOLE all and 10O MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: =® EXTRACTION: Vapor/ Water ❑ HAMMER/DRIVEN CASING THICKNESS 0 . 217 'F/0 . 23UV TYPE OF CASING: ❑ STEEL © PVC ❑ OTHER —❑ SOIL VAPOR PROBE ❑ MUDROTARY DEPTH OF GROUT SEAL 2 , and 191 TREMIE TYPE TO BE USED: ❑ AUGERS EI HOSE ❑ PIPE —❑ SOIL BORING ❑ PUSH POINT (GP/ CPT) GROUT SEAL PUMPED: 0 Yes ❑ No (MAXIMUM FREE FALL DEPTH IS 30 FT) =® INJECTION (Le At Soame Ozone) ❑ HAND AUGER GROUT SPECIFICATIONS Portland. Type 11 _[] OTHER: . [] OTHER: APPROX. BORING DEPTH 15 t and 251 EI BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING EI No ❑ Yes: Casing Dia: Casing Depth: Boring Dia: COMMENTS: see EHD approval letter 29 ,June 2011 . NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: (CHECK ALL THAT APPLY) _# OF WELLS) TO BE DESTROYED ❑ OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑ EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑ AUGERS ❑ HOSE ❑ PIPE ❑ MUSHROOM CAP AT L3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulations, andgFlappliwbl alit la Laws. Signed \/ / -^ Title/Company Advanced GeoRaviro�ntal Inc . Print Name Daniel Villanueva Date 05/09/2.0 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE SITE ADDRESS S 17 W . Frern o n I- c5+r a e,f" WORK PLAN DATED {� D Y� ILL n L d% 0 1 t APPLICATION ACCEPTED BY VI 4. +h YC PYI. ti!4 'FYt �Ve .n DATE ISSUED S 11 17_ AREA / 4SQ GROUT INSPECTION BY 1 1(Y y 1yYLaA� FINAL INSPECTION BY DATE 5 `a: Z- DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: zn Sf All &yic eV t well and �fovr Z A S WG {lS ACCOUNTING ONLY: AID # FAC # [PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE SERVICE RO # INVOICE REQUEST PR # 1 $ 125x ( 2S oa 3 ,570 s4 �(/f12 s - il - > z SR# 00 t, 4 '? 08 3505- 3 '7S, or0 3 qs 0 -0 (350RIO 0) v170 1111` 1Od 0 • d0 PR # z900) j C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC